Data estimate true cost of copayments to patients
AN INDEPENDENT assessment of the federal government’s proposed $7 patient copayment on GP and diagnostic services has estimated that patients with type 2 diabetes could add an extra $120 a year to the cost of their GP consultations, with those holding a concession card paying an extra $70. The Bettering the Evaluation and Care of Health (BEACH) findings used 2013‒2014 BEACH data to estimate the additional out-of-pocket costs to general practice patients resulting from the proposed $7 copayments for GP, pathology and imaging Medicare services; the proposed $5 increase in the Pharmaceutical Benefits Scheme (PBS) copayment; and the combination of both policies. The assessment found more than a quarter of adult GP consultations involved at least one investigation (total added cost for the consultation of at least $14), with about 3% of adult GP consultations including imaging and pathology tests (copayment = $21). The average total additional annual cost was estimated to increase with patient age, from about $35 per year per child to about $94 a year for patients aged 65 years and over. The researchers said that although the cost of PBS medications would increase by 80 cents per prescription for concessional patients compared with $5 for general patients, the actual cost increase for medications would be higher for concessional patients due to the number of medications affected. “If both policies were introduced the average annual additional cost to patients increases with age from $36 for children to $122 for patients aged 65+”, the researchers wrote. “International evidence overwhelmingly suggests that the most efficient, effective and equitable health systems have a strong primary care focus. We have shown that these policies will create a larger price signal than previously suggested in the media.” They wrote that evidence suggested long-term health costs would be higher due to patients deferring necessary care, resulting in increased hospitalisation and progression of disease. “We believe that if Australia is to maintain an efficient and equitable health care system, then general practice requires investment, not reductions.”

No data to support pelvic exams in asymptomatic women
A SYSTEMATIC review to evaluate the benefits and harms of routine screening pelvic examination in asymptomatic, non-pregnant adult women who are not at increased risk for gynaecologic cancer has found data to support it is “scant”, despite its widespread use on clinical practice. The review, published in Annals of Internal Medicine, included 32 studies and 20 guidelines and related documents. “Our primary conclusion is that no data support the use of routine pelvic examination (excluding cervical cytologic examination) for reducing the morbidity or mortality of any condition”, the authors wrote. “We identified no studies evaluating the mortality and morbidity benefits of bimanual examination to screen for ovarian cancer in asymptomatic, average-risk women, and most major professional and governmental groups recommend against such screening”, they wrote. “We found no studies that assessed the morbidity or mortality benefits of routine pelvic examinations for the detection of cancer (ovarian, uterine, bladder, vaginal, or vulvar) or nonmalignant conditions (pelvic inflammatory disease, fibroids, warts, atrophic vaginitis, or any other gynecologic condition) in asymptomatic, average-risk women.” However, they did find “limited evidence” which suggested screening pelvic examinations were associated with pain, discomfort, fear, anxiety, or embarrassment in about a third of women, and could lead to unnecessary, invasive, and potentially harmful diagnostic procedures. In the same issue of Annals of Internal Medicine the American College of Physicians published guidelines that made a “strong recommendation” against performing screening pelvic examination in asymptomatic, non-pregnant adult women. An accompanying editorial said the recommendation would be controversial as pelvic examination “has long been considered a fundamental component of the well-woman visit”. The editorial said the pelvic examination had become more of a ritual than an evidence-based practice, and that doctors who continued to use it “should at least be cognizant of the uncertainty of benefit and the potential to cause harm through a positive test result and the cascade of events that follow”.

Genetic screening of children can diagnose coeliac disease
A LARGE, international, prospective cohort study, published in the New England Journal of Medicine has found that screening of genetically susceptible infants can lead to a diagnosis of coeliac disease at a very early age. The study found 26% of children with the highest-risk haplotype developed coeliac disease autoimmunity by the age of 5 years. The researchers said the findings could be useful if the initiation of screening in at-risk children was considered in the future. The research included 6403 children with HLA haplotype DR3–DQ2 or DR4–DQ8 who were studied prospectively from birth in the US, Finland, Germany and Sweden. Coeliac disease autoimmunity developed in 786 children (12%). Of the 350 children who underwent intestinal biopsy, 291 had coeliac disease confirmed. The proportion of children with persistently high levels of tissue transglutaminase antibodies was highest among those who were homozygous for the DR3–DQ2 HLA haplotype — 352 of 1374 children (26%), as compared with 298 of 2612 children (11%) with the DR3–DQ2/DR4–DQ8 haplotype, 107 of 1303 (8%) who were homozygous for the DR4–DQ8 haplotype, and 29 of 1114 (3%) with the DR4–DQ8/DR8–DQ4 haplotype. The risk in the children with DR3–DQ2 homozygosity was more than 2.5 times that in the group with a single DR3–DQ2 haplotype and more than five times that in the lowest-risk groups. The researchers said their findings confirmed an earlier observation that DR3–DQ2 homozygosity is associated with an earlier age at the onset of coeliac disease autoimmunity, and that the effects were compounded by a family history of coeliac disease, female sex and country of residence. Even after matching for haplotype, Swedish children had a substantially higher risk of both coeliac disease autoimmunity and coeliac disease than did those from the other countries studied. “Our findings indicate the need for study of the complex relationships among genetic, environmental, and gestational factors that may play a role in the development of celiac disease in early childhood”, the researchers wrote.

Long-term hypertension linked to psoriasis risk
A PROSPECTIVE cohort study examining the association between hypertension, antihypertensive medication use and risk of incident psoriasis in women has found a prior history of hypertension of 6 years or more is associated with an increased risk of psoriasis. The research, published in JAMA Dermatology, included 77 728 US women from the Nurses’ Health Study who provided biennially updated data on hypertension and antihypertensive medications from 1996 to 2008 and who reported no diagnosis of psoriasis at baseline. The researchers found 843 incident psoriasis cases which showed that, compared with normotensive women, those with hypertension of 6 years or more were at a higher risk of developing psoriasis. Specifically, they found that hypertensive women, whether medicated or non-medicated, were more likely to develop psoriasis. Among the individual antihypertensive drugs, only β-blockers were associated with an increased adjusted risk of psoriasis after regular use for 6 years or more. Other widely used antihypertensive drugs, including thiazide diuretics, calcium channel blockers and angiotensin-converting enzyme inhibitors were not associated with the risk. The researchers found the risk of developing psoriasis was not apparent among women who had hypertension for less than 6 years. They wrote that the finding was consistent with the existing concept that psoriasis was associated with a chronic inflammatory state. “Hypertensive participants with longer disease durations may have a greater possibility of developing psoriasis later because of the long-lasting increased levels of systemic oxidative stress and inflammation”, the researchers wrote. The author of an accompanying commentary wrote that there was a lack of recognition of medication-related psoriasis exacerbations by health care professionals. The author said that when dermatologists recommended a medication be discontinued, “they need to coordinate care with other health care professionals to ensure that the patient is offered appropriate alternative treatments for substitution. Narrowing this practice gap will help reduce medication-related psoriasis flares and significantly improve long-term outcomes in patients with psoriasis”.

A third of knee arthroplasties may be inappropriate
A US study published in Arthritis & Rheumatology has found that about a third of total knee arthroplasty (TKA) surgeries are inappropriate. The multicentre, longitudinal cohort study used an appropriateness classification system adapted for use on patients undergoing TKA in an osteoarthritis dataset and included a variety of preoperative data including pain and physical function scores, extent of radiographic arthritis, age and knee joint impairment. Prevalence rates for classifications of appropriate, inconclusive and inappropriate surgeries were calculated. Of the 205 patients who underwent TKA surgery over a 5-year period, the mean age was 66.9 years and 59.5% were female. The researchers found 44.0% of the cases were classified as appropriate, 21.7% as inconclusive and 34.3% inappropriate. The researchers wrote that the variation in the characteristics of patients undergoing TKA was extensive. “These data support the need for consensus development of criteria for patient selection among practitioners in the US treating potential TKA candidates”, they wrote. “Among the important issues, consensus development needs to address variation in patient characteristics and the relative importance of pre-operative status and subsequent outcome.” They wrote that potential TKA surgery patients should consider their symptomatic severity and psychological readiness among other issues, as well as surgical risk. They said surgeons should consider a host of patient-specific variables when recommending for or against a primary TKA surgery. “Ultimately, surgical decisions likely include many other issues beyond those included in any single set of appropriateness criteria and as a result, we suspect that any appropriateness criteria will have limitations that may restrict application for some individuals”, they wrote.

Glucocorticoid injections no benefit in spinal stenosis
RESEARCHERS have found no significant differences in pain measurements for patients with lumbar spinal stenosis randomly assigned to receive glucocorticoids plus lignocaine (lidocaine) and those assigned to lignocaine alone. The randomised control trial published in the New England Journal of Medicine included 200 patients who received an epidural injection of glucocorticoid–lignocaine and 200 who received lignocaine alone. The two groups had similar baseline characteristics, except that the duration of pain was shorter in the lignocaine-alone group. Patients in both treatment groups had decreased pain and improved function at 6 weeks which did not differ significantly. At 3 weeks, the glucocorticoid– lignocaine group had greater improvement than the lignocaine-alone group, but the differences were clinically insignificant. “Potential explanations for the similar improvements in the two groups include placebo effects, regression to the mean, the natural history of spinal stenosis, and other factors present in both study groups, including contact with study personnel and receipt of lidocaine”, the researchers wrote. “We did not include a sham injection group and thus cannot assess whether lidocaine alone conferred a benefit.” Serious adverse events were rare in the study, although more events were reported in the glucocorticoid–lidocaine group than in the lignocaine-alone group. “Despite a rapid increase in the use of epidural glucocorticoid injections for lumbar spinal stenosis, there is little evidence of effectiveness”, they wrote. The author of an accompanying editorial wrote that on the basis of the mostly negative results of the study and lack of other rigorous data to support the use of glucocorticoid injections in patients with lumbar spinal stenosis, “I will remain cautious in prescribing epidural glucocorticoid injections”. “Patients should be informed that the current best available data have not provided support for a clinically significant long-term benefit overall and that complications are possible”, the author wrote.

Insulin pump improves type 2 diabetes control
NEW research shows treatment with an insulin pump is better at reducing glycated haemoglobin than multiple daily injections in patients with poorly controlled type 2 diabetes. The international, multi-centre, randomised open-label controlled trial, published in The Lancet, included 168 patients using an insulin pump and 163 on multiple daily insulin injections. The study included participants aged 30–75 years, but excluded pregnant patients, those on very high insulin doses and patients who had two or more hypoglycaemia-related seizures or comas within the previous 6 months, or significant diabetic complications. At baseline the participants had glycated haemoglobin (HbA1c) above the target range (≥ 8•0% and ≤ 12%). The researchers found the pumps outperformed multiple daily injections on several measures, with those on pumps achieving a significantly greater reduction in average blood sugar levels than those who used multiple daily injections at 6 months (HbA1c difference of -0.7%). Twice as many patients also reached the target range of 8% or less in the pump-therapy group compared with the injection group (55% v 28%). Patients using pumps also, on average, had shorter duration of hyperglycaemic events. Time spent in hypoglycaemia was similar in both groups. After 27 weeks, the daily dose of insulin was 20% lower with pump therapy than with multiple injections and no weight difference was observed in either group. The author of an accompanying commentary wrote that the study “provides a compelling case for the clinical effectiveness of insulin pump treatment in type 2 diabetes, suggesting that it can help improve glycaemic control in this difficult to treat group of patients who are unable to achieve glucose control despite increasing doses of insulin”.

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